Common Obstetric Emergencies by Dr. Ali Kareem final year medical student Al Mustansiriyah University College of Medicine \ Baghdad \ IRAQ \ 2018

1. Obstetric Emergencies
Management
presented by : Ali Kareem
final year medical student

2. Definition
• An emergency is defined as a serious situation or
occurrence that happens unexpectedly and demands
immediate action.
• In obstetrics, emergencies can be classified as
maternal (occurring antenatally and post-natally) and
fetal.
• Direct deaths are defined as those resulting from
obstetric complications, Indirect deaths as those
resulting from pre-existing disease that has been
worsened by pregnancy.

3. Approach
• many of the fetal obstetric emergencies require the
use of specific drill, the maternal emergencies can
make use of the common ABC approach used for
all adult emergencies. When called to any
emergency situation, the first action should be to
call for help.
• After this, a systematic evaluation and
resuscitation should be conducted in the following
order:

4. Approach
• After this, a systematic evaluation and resuscitation
should be conducted in the following order:
• 1. Airway
• 2. Breathing and ventilation
• 3. Circulation with volume replacement and control of
bleeding
• 4. Disability
• 5. Environment and exposure.

5. Approach
• On approaching the patient, first speak to them to
find out whether they are able to respond. In
addition to being an important form of
communication, this also reveals important
information. If the patient responds appropriately,
they must have an open airway and be able to
move sufficient air to speak. Furthermore, it also
gives useful information about neurological status.

6. Approach
• In contrast, if the patient is unable to respond, it
should trigger the immediate call for help and
assessment of airway, breathing and circulation. In
pregnant patients (20 weeks or more) and in the
immediate postpartum period, the enlarged uterus
compresses the inferior vena cava, thus reducing
venous return to the heart when the patient is lying
flat on their back. It is therefore extremely important
to tilt the patient to the left to aid resuscitation (left
lateral tilt, Figure 16.2). This will lift the heavy uterus
away from the abdominal vessels, improving the
venous return to the heart and aiding the
resuscitation attempt.

7. Airway
• First, check in the mouth for any obstructing
material, such as blood or vomit, and remove
using suction. Next, open the airway by using
either the head tilt and chin lift, or a jaw thrust.

8. Breathing
• Having opened the airway, the breathing should be
assessed for 10 seconds by looking for chest
movement and listening and feeling for signs of air If
the airway is open and the patient breathing, high
flow oxygen should be administered via a face mask.

9. Circulation
• Assess pulse, skin color, temperature and any
external bleeding.
• Intervention includes: two large bore cannulae should
be inserted into both antecubital fosse to allow blood
to be taken for full blood count, cross-matching, and
biochemistry, fluid resuscitation and drug
administration.

10. CPR
• If there is no circulation, or there is some uncertainty,
cardiopulmonary resuscitation (CPR) should be
commenced immediately. This begins immediately
with 30 chest compressions followed by two
ventilation breaths movement.

11. Causes of obstetric
emergencies

13. Inversion Uterine Causes
Rupture
Uterine atony
Amniotic fluid embolus Sudden maternal collapse
Pulmonary embolus
Shock : septic
Cardiac cause : MI
Biochemical cause: hypoglycemia
Anesthetic events

14. Management of specific obstetric
emergencies
• Haemorrhage
• Obstetric hemorrhage can occur antenatally or post-
natally, and both can present as obstetric emergencies.
• Antepartum haemorrhage
• Antepartum hemorrhage (APH) is any bleeding occurring
in the antenatal period after 20 weeks gestation. It
complicates 2–5 per cent of pregnancies.

15. Placental abruption Placenta praevia
is separation of a normally sited
placenta from the uterine wall
Is a placenta that has implanted into
lower segment of the uterus
Management Management
Should be initially resusciated using
approach ABC. Mx depend on the problem
. realization
that true blood loss may be far greater than
the blood loss seen . In severe cases fetus
will be dead and vaginal delivery
accelerated by artificial ROM once mother
is stable.
Should be initially resuscitated using
approach ABC . If the bleeding minor and
fetus uncompromised the PT should
admitted for observation 24hr and major
bleeding (recurrence) should be
admitted as inpatients from 34weeks with
fluid resuscitation and delivery of fetus by
CS .
Other causes of APH include cervical
bleeding
(ectropion, post-coital), genital tract
infection,
genital tract tumours, a show and vasa

16. Postpartum hemorrhage
• Is probably one of the most common cause of
obstetric emergency
• It is defined as:
❖ Primary PPH. Loss of 500 mL blood from the genital
tract within 24 hours of delivery;
❖ Secondary PPH. Loss of 500 mL blood from the
genital tract between 24 hours and 12 weeks post
delivery. It is considered to be minor if the blood loss
is between 500 and 1000 mL and major if it is greater
than 1000 mL.

17. Management of severe postpartum
hemorrhage
⮚ Call for Help ( senior / anesthetist )
⮚ Oxygen by mask initially
⮚ 2 x 14 gauge intravenous lines
⮚ Full blood count and clotting studies
⮚ renal function and liver function tests
⮚ Cross-match at least 6 units of blood
⮚ Fluid resusication intravenously
⮚ Notify blood bank and consult haematologist
⮚ Foley catheter into the bladder and fluid chart balance
⮚ Transfuse blood as soon as possible uncross matched same
group as mother
⮚ Central venous pressure and arterial lines
⮚ May need fresh frozen plasma, platelets and cryoprecipitate
⮚ Eliminate the cause – deliver the baby and placenta

18. Case
• A 31-year-old woman is admitted with contractions at 40
weeks’ gestation. She is G4P1A2, her last pregnancy ends
with elective Caesarean section for malpresentation. She
admitted with spontaneous rupture of membranes after
which she had begun to contract regularly. Cervix was 4cm
dilated. The head was in the occipito-transverse position.
Three hours later the woman reported more severe pain
which did not disappear between contractions. At that time
vaginal bleeding of approximately 200mL of fresh blood
was seen.
• By examination: heart rate is 105/min and blood pressure
105/58 mmHg. The uterus is soft but very tender, with easy
palpation of fetal parts. On PV examination the cervix is
6cm and the fetal head feels high in the pelvis.

19. Diagnosis?
Management?
Further complications?

20. Uterine rupture
Emergency care
Transfer to theatre for
laparotomy
Preserve the uterus
Hysterectomy
Management

21. Uterine rupture
Complications
Death Cerebral palsy
Maternal
Fetal
PPH Hysterectomy

22. Case
A 34-year-old primigravida delivered a healthy term
infant at a midwife’s clinic after a reportedly
uneventful labor. The mother developed a severe
hemorrhage in the third stage of labor and was
immediately referred after initial resuscitation with
crystalloids. On arrival at the tertiary hospital, her
pulse rate was 100 beats/min and systolic blood
pressure was 95 mmHg despite slow but active
vaginal bleeding.
Diagnosis?
Management?

23. Uterine Inversion
⮚ Management:
1. Resuscitation.
2. Replacement of the uterus:
• Manually (Johnson’s method).
• Surgically.
• O'Sullivan’s hydrostatic method.

26. Fetal Emergencies

28. • The incidenc is
1:500 deliveris.
• Deep variable
decelerations.

29. Management
• If the cord is through the vulva replace in the vagina.
• Urgent cesarean sesction is required unless the
cervix is fully dilated and assisted vaginal delivery
can be safely performed.
• I.V. line with large bore cannula.
• Relive the pressure on the umbilical vein by placing
the mother in a head-down position, the patient
should be in all fours position with the hips elevated.

31. The presenting part should be pushed up
either by doctor’s hand placed in the vagina
or by filling the bladder with 500 saline.

32. • Before commencing C/S the bladder should be
emptied, listen ti fetal heart to be sure that the
fetus is alive.
Prognostic factors:
• Gestational age.
• Other complications eg: IUGR.
• Duration of cord prolapse (10 min may cause
cerebral damage, 20 min may lead to death).

34. • Incidence from 0.2 - 1.2%.
• Prevented by cesarean section.
Risk factors:
• Large baby .
• Small mother.
• Diabetes mellitus.
• Maternal obesity.
• Post maturity.
• Previous shoulder dystocia.
• Prolonged labour (first & second stage).
• Assisted vaginal delivery.

35. Complication:
• Cerebral damage.
• Stretching of brachial
plexus & nerve
damage.
• Erb’s palsy